Depersonalization in the DSM-5

For almost half a century feeling unreal has been known as DPD, an abbreviation for Depersonalization Disorder. Now it is about a year since feeling unreal has been renamed. The new fifth edition of the DSM – an official psychiatric Bible - has established a new name - Depersonalization/Derealization Disorder or DDD. Another of the DSM-5’s innovations is narrowing the spectrum of depersonalization by excluding presentations related to substances or medication and other medical conditions. Let’s look closely at what these innovations mean.

Depersonalization and derealization are deeply connected phenomena. Depersonalization refers to the experience of one’s self, where as derealization - to the experience of unreality of the world around. Since the first formulation of DP as a diagnostic category by the DSM-II in1968, the term depersonalization served as a general name for feeling unreal and includes derealization as an associated feature. This tradition was kept through the three generations of DSMs: II, III and IV. The DSM-5 has changed this status quo, adding derealization to depersonalization in the very name of this disorder.

This step appears consistent with the historical frame. Initially depersonalization and derealization are treated as parts of one condition. The first cases of feeling unreal, which are presented by the French otolaryngologist, M. Krishaber, under the name of “cerebro-cardial neuropathy” in 1873, include both unreality of self and unreality of world. Seven years later, in 1880, Swiss thinker Henri Amiel coins the term depersonalization to name his own experiences of unreality both of himself and the world around him.

An entire half a century later, in 1935, British physicians Mapother and Mayer-Gross distinguish derealization as the feeling of unreality of the world around from depersonalization as the feeling of unreality of one’s self. Nevertheless, many researchers and practitioners have kept using depersonalization as a major term, considering derealization as a part of depersonalization. The DSMs have followed this approach. The definition of depersonalization in DSM-II (1968) states that depersonalization “is dominated by a feeling of unreality and of estrangement from the self, body, or surroundings.” Derealization is not mentioned specifically here, but clearly is included in depersonalization as “a feeling of unreality and of estrangement from… surroundings.” The following DSM-III and DSM-IV do employ the term derealization though not as a name of a disorder itself, but as an associated feature of depersonalization disorder.

However, in contrast to the American DSM, the International Classification of Diseases by World Health Organization (ICD) categorizes feeling unreal as depersonalization-derealization syndrome. In this sense, the DSM 5’s move from depersonalization disorder to depersonalization/derealization disorder brings the American classification closer to the International.

If the DSM-5’s name change from DPD to DDD seems a clinically reasonable choice, then the way this change is presented seems more confusing than convincing. The DSM-5 reads, “There is no evidence of any distinction between individuals with predominantly depersonalization versus derealization symptoms. Therefore individuals with this disorder can have depersonalization, derealization or both.” The first statement raises a question: is it at all possible to find individuals – with “depersonalization versus derealization,” or just any individuals - who do not have “any distinction?” Further, this first statement does not provide logical ground for what follows after “therefore” in the conclusive part of the passage. DDD appears to be a terminological preference that also unifies the American and the International psychiatric classifications rather than a principled clinical or theoretical innovation.

2. The cause of depersonalization.

If the previous DSMs carefully avoid speculation regarding causes of depersonalization, the DSM-5 establishes a special criterion related to causality of depersonalization. In general psychiatry infamously struggles with the problem of etiology – causes of disorders. This is especially true for depersonalization. Why does a particular person have a particular form of depersonalization at a particular time? Even though neuroscience, genetics, psychology and other disciplines contribute significantly to understanding of the development of depersonalization, the exact cause of depersonalization remains unclear in the majority of cases. The DSM-5 does not suggest the criterion for a direct cause of depersonalization. The DSM-5 offers the criterion of cause that is an exclusion criterion, namely, causes the presence of which should exclude the diagnosis of depersonalization.

The criterion D (the fourth in five criteria for DDD) specifies that DDD “is not attributable to the physiological effects of substance (e.g. drug of abuse, medication) or another medical condition (e.g. seizures).”

Thus, the DSM-5 excludes two well-known groups which have been traditionally considered as depersonalization. The first excluded group is those numerous cases of depersonalization which appear in relation to using substances, including notorious episodes of post-marijuana or post-psychotomimetics depersonalization. The second excluded group covers conditions which have been historically considered as depersonalization presentations of epilepsy. Classical works on depersonalization describe depersonalization that appears during the course of parietal or temporal lobe epilepsy.

The DSM-5 has narrowed the spectrum of depersonalization, reserving the diagnosis of DDD only for those presentations of feeling unreal which do not have evident connection to other specific conditions or disorders. Different presentations of feeling unreal observed in cases of posttraumatic stress disorder, anxiety, depression, obsessionality and substance-induced disorders, as well as epilepsy or other medical conditions do not meet formal criteria for DDD.

Summarizing the DSM-5 innovations in categorization of depersonalization, one could remark that DDD appears to be a somewhat more “cleaned-up” version of DPD. No breathtaking discovery or revolutionary theoretical reformulation is evident, but rather an attempt to reorganize already known data. It is unlikely that feeling unreal under the name of DDD is becoming more easily diagnosed or more successfully treated than the old DPD.

Was any legal advice obtained when drafting the DSM? What am I thinking? The medical profession are above the law, are infallible and never harm - and should be given every opportunity to judge and label. Wouldn't it be wonderful if we could all be judged and labelled by the medical profession - and it can be done so simply - a family member, a school teacher, a co-worker, a boss, could just answer a few questions on a checklist - all it takes is a few minutes of any obviously insightful acquaintance's time - and that is it - categorized and stigmatized for life

Thank you – your post has true merit. And some stimulating measure of bitter irony. Of course: Label jars – not people. To diagnose is never to define the person as a whole. Diagnosis is rather the technical way of characterizing just one part of this whole. The medical dimension is interwoven with the legal, ethical, social and cultural dimensions. And “knots” can be pretty tangled. Let’s talk about this.

Your comment "To diagnose is never to define the person as a whole" is not the case - as to diagnose someone as "Neurotic", "Psychotic", schizophrenic" "Leper" means that these diagnosed become "A Neurotic", "A Psychotic", "A Schizophrenic" "A Leper"

Children are routinely diagnosed on the basis of checklists completed by school and parent - boxes are ticked for perceived behaviours which are not acceptable to school teacher and or parent who like peace and quiet and or over anxious parents who wrongly believe that the child is suffering from all the negative emotions they are suffering from . Checklist compilers can often be the child's persecutor. Perceived behaviours being, for example, "temper outbursts" (over control of suppressed emotions - which include any emotion such as disappointment, fear, frustration, anxiety, etc )being wrongly perceived as "temper tantrums" (under control because of failure to get instant gratification). The child who rightly questions a person's authority to over control him will qualify for a tick in the box for "argumentative / defiant" The child has no say, is not examined nor observed - and even in the unlikelihood if a child is asked why are you so angry the child may not know and simply say "he she was annoying me by breathing too loudly". There is a saying "we are rarely angry for the reason we think we are angry. So if an adult doesn't know why he is angry (anger is often a representation of depression so if an adult is confused by his emotions how can a child be expected to understand his. Also children don't often realise that they are being bullied. A young child who has misbehaved and is told by the class "we can't play with you because you are bold and some of your bold might get onto us" will believe that he / she is bold and will be upset and angry and wont want to explain why.

Also a child labelled with a disorder, eg. ODD as spurious disorder with no biological basis will be regarded as having the dozen or so symptoms when all that is required is 4 - and the 4 he or she has might be traits of giftedness - a condition for want of a better word routinely misdiagnosed as disorder (or may have the more innocuous traits - some traits are far worse than others and the same label applies regardless). Few if any Psychiatrists appear to have knowldedge of the Betts & Neihart 6 Profiles of Giftedness (or possibly more profiles in the updated version). This document will show how very easy it is to misdiagnose a gifted and or talented child as having a "disorder", And why use such an offensive and stigmatizing term as "disorder". Why use any term? Why no simply identify the reasons for the behaviours wrongly called "symptoms" which in any case are "traits" of normality. Why not take the common sense "Nanny 911" approach. Nanny always finds that the "out of control" child is simply using coping mechanisms in an unsuitable environment and it is always the environment (simnply inexperienced parents - who have nothing to guide them - as most people move away from their own parents and lose out on mentors)

I feel like im in a dream all day every day. Sometimes I have pain behind my eyes and feel a bit anxious. What is this and is there a cure for it? Please help I have been suffering bad for about 3 years now but it started 28 years ago but wasn't this bad